Request For Academic and/or Physical Accommodations

Student Information

Student name: (Required)

Your Student ID Number:

Preferred phone number:

Your CMN email: (Required)

Trimester:
FallSpringSummer

Academic Year:
2022 - 20232023 - 20242024 - 20252025 - 20262026 - 20272027 - 20282028 - 20292029 - 20302030 - 2031

Accommodation Information

Which types of accommodation are you requesting? (Required, check all that apply)
AcademicPhysical

In your own words, please describe your need: (Required)

What type of accommodations have you been provided in the past?

What type of academic accommodations are you requesting? (Required, check all that apply)
Attendance and Participation
Excused absencesExtended time for written assignments/projectsDo not penalize student for late arrival to classAllow to leave class for a few minutes as necessaryOther
Exams
Extended time (1.5 – 2 times the normal time)Oral quizzes and examsDistraction reduced spacePermission to make up missed quizzes and examsChunkingLaptop for written examsPermission to stagger examsReaderOther
Assistive Devices and Services
Recording deviceLaptopCalculatorPersonal Braille DeviceWheelchair accessible locationNote taker for coursesASL InterpreterWorkstation modificationOther
Textbooks/Course Material
Books on tapeLarge printBrailleCaptioning for any filmsElectronic format, ie, doc. or pdf.Other
The following classroom suggestions would be helpful to me. I understand that they are not ADA required accommodations.
Read aloud PowerPoint slides and anything written on the board.Repeat questions asked by other students.Face this student when speaking so he/she may lip read.Provide a study guide prior to exams.Provide a copy of PowerPoint notes.Give any necessary feedback to this student privately.Provide gentle cues if this student is speaking too long or off topic.

Statements of Understanding

I authorize the Office of Academic and/or Student Affairs to provide verification of my disability to faculty, the Deans of Student Affairs and Academic Affairs and professional staff at CMN when necessary to clarify my need for specific disability-related accommodations.

I have read and understood these statements.